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KHI.ORG Informing Policy. Improving Health.

2017 KANSAS LEGISLATIVE PREVIEW Anticipating key health policy themes

Introduction Democrats. Forty-six of the representatives are new for 2017, but six of them have previously served The 2017 legislative session will mark the in the House. (These numbers include the recent first year of a two-year cycle. While issues announcement of Rep. Marvin Kleeb’s retirement on from previous sessions—such as the status Jan. 10 and the election of his successor, Abraham of the state’s psychiatric hospitals, Medicaid Rafie.) ISSUE BRIEF expansion and medical marijuana—will likely resurface, all will be in the form of new bills. KanCare Dozens of new faces in the Capitol also mean the Legislature itself will have a new During the 2017 session, legislators will have the character. opportunity to debate and respond to a number of issues related to the current and future operation of As a result of the general election in the Kansas Medicaid program, known as KanCare. November 2016, the has gone from 32 Republicans and eight Democrats to 31 Republicans and nine KanCare 2.0 Democrats. Fourteen of the senators Although the initial three-year term of state contracts are new, although five of them were in for the three KanCare managed care organizations the Kansas House in 2016. The Kansas (MCOs) ended December 31, 2015, the MCOs have House went from 97 Republicans and continued to operate under an optional two-year 28 Democrats to 85 Republicans and 40 extension of the original term of their contracts.

SENATE 4 116 13 R Kansas Kansas 2017 18 R 8 D 1 D NEW NEW Democratic Republican Lawmaers Lawmaers

TOTAL JANUARY 2016 32 R 8 D

HOUSE

31 R 15 D 54 R 25 D 2017 NEW NEW

2016 97 R 28 D

0 30 60 90 120 150

2017 KHI/17-02 It was anticipated that the Kansas Department of Health and Environment KanCare Performance (KDHE) would issue a new request for proposals (RFP) before the end of In fiscal year (FY) 2016, Medicaid 2016 to select the MCOs that would be operating KanCare beginning on and the Children’s Health January 1, 2018. However, on November 18, 2016—during a meeting of the Insurance Program (CHIP) Robert G. (Bob) Bethell Joint Committee on Home and Community Based covered a monthly average Services and the KanCare Oversight Committee—KDHE officials announced of about 426,000 people at that the renewal process for KanCare was being placed on hold and the RFP an annual cost of almost $3.4 was “delayed indefinitely.” On December 16, 2016, Lt. Governor Jeff Colyer billion to the state. In Kansas, announced that the state had renewed the existing MCO contracts and 25.1 percent of all Medicaid and would not request new bids until late 2017. Colyer also stated these changes CHIP enrollees are seniors or were the result of uncertainty regarding what the election of Donald Trump people with disabilities, but this combined population incurs 70 as president and Republican control of Congress might mean for state percent of total state spending Medicaid programs. for these programs. Children and families, including children in CHIP, account for approximately 75 percent of Medicaid and Kansas Senate 2017 Leadership CHIP enrollees and incur 30 percent of state spending. In FY 2016, annual Medicaid and CHIP Majority President Minority Leader spending averaged $2,925 per (Republicans) (Democrats) Susan Wagle Anthony Hensley pregnant woman, child or family member, compared to $23,863 per enrollee with a disability and ice President: Jeff Longbine Assistant Leader: Laura Kelly $15,540 per senior enrollee.

Majority Leader: Jim Denning hip: Oletha Faust-Goudeau During the November 2016 KanCare Oversight Committee Assistant Leader: Vicki Schmidt Agenda Chair: Marci Francisco meeting, legislators heard from a number of KanCare beneficiaries and providers regarding concerns hip: Elaine Bowers Caucus Chair: Tom Hawk about the administration of benefits and the timing and processing of provider Kansas House 2017 Leadership reimbursements. They also heard from a representative of Leavitt Partners, a health policy Majority Speaer of the Minority Leader consulting firm engaged by the House (Republicans) (Democrats) Kansas Hospital Association, Ron Ryckman, Jr. Jim Ward the Kansas Association for the Medically Underserved, and Speaer Pro Tem: Scott Schwab Assistant Leader: Stan Frownfelter the Kansas Medical Society, to conduct an assessment and Majority Leader: Don Hineman hip: Ed Trimmer analysis of KanCare. The firm concluded the program had “not Assistant Leader: Tom Phillips Caucus Chair: met its original rationale and commitments.”

hip: Agenda Chair: Brandon Whipple KDHE countered by reporting a number of positive quality Caucus Chair: Policy Chair: Adam Lusker and outcomes measures. The KanCare Oversight Committee responded by recommending

2 January 2017 2017 Kansas Legislative Preview specific program changes, and it is likely that Medicaid Expansion legislators will be asked to consider additional action to respond to the concerns expressed by KHI estimates 152,000 people—including 98,000 beneficiaries and providers. adults—would newly enroll in KanCare if the state expanded Medicaid up to 138 percent of the federal During the November meeting, legislators also poverty level, as provided under the Affordable Care continued to hear reports of lengthy delays in the Act (ACA). During the 2016 session, the Kansas Hospital processing of Medicaid applications, specifically Association introduced two identical bills, entitled those for individuals admitted to skilled nursing “KanCare Bridge to a Healthy Kansas Program,” in the facilities. KDHE reported in September that a House and Senate. A 2015 study by Manatt, Phelps and backlog of applications was being resolved and had Phillips, LLP, had suggested the state could generate been reduced significantly over the summer. The new revenue and savings to offset the cost of expansion. KanCare Oversight Committee asked the agency to However, neither bill received a hearing. provide an updated report regarding the number of Since June 2016, the Alliance for a Healthy Kansas—a pending nursing facility applications. nonprofit entity backed by five Kansas health foundations and more than 70 organizations that Budget Cuts support the expansion of Medicaid—has conducted more than 20 community meetings across the state with the In November, KanCare Oversight Committee stated goal of educating Kansans about the “economic members also heard from health care providers and health benefits” of expansion. Expansion advocates about the impact of the 4-percent cut in have also been conducting a series of regional meetings reimbursements that was made by Governor Sam with newly elected legislators. Brownback in May 2016 to help balance the state Recent polls conducted by the Kansas Hospital budget. Legislators heard concerns that the cuts Association and the Docking Institute of Public Affairs had shifted costs from the state to providers, and have found that more than 60 percent of Kansans that the effect could be a loss of providers willing support expansion of KanCare, particularly if it is budget- to accept KanCare members. neutral or revenue-generating.

The KanCare Oversight Committee recommended Given recent announcements regarding the state’s reversing the 4-percent cuts. However, revenue budget shortfalls, along with the outcome of the projections by the Consensus Revenue Estimating November 2016 elections, it is not clear how the 2017 (CRE) group in early November indicating a $346 Legislature may respond to the introduction of new million shortfall in revenues for FY 2017 and Medicaid expansion bills. Both President-elect Donald an additional drop in FY 2018 revenues may Trump and Republicans, who now control both chambers complicate the Legislature’s efforts to restore the of Congress, have stated their intent to repeal the ACA. payments. The U.S. House Republican plan issued June 2016,

2017 HealthRelated Committee Chairs

Insurance Jene Vickrey (R) Financial Institutions and Insurance Jeff Longbine (R) SENATE HOSE Health and Human COMMITTEE COMMITTEE Services CHAIRS CHAIRS Dan Hawkins (R) Public Health and Welfare Vicki Schmidt (R) Social Services Budget (R) Source: Photos from kslegislature.org and brendalandwehr.com.

2017 Kansas Legislative Preview January 2017 3 “A Better Way,” would remove expansion as an Prescription Painkillers/Opioid option for states that have not yet expanded, and proposed a gradual reduction in the enhanced Addiction match rate for states that have already expanded. In 2014, more than 47,000 people in the United States died from drug overdoses, more than any Adding to the uncertainty of Medicaid expansion year on record. At least half of all drug overdose are Republican proposals to transition federal deaths involve a prescription opioid, and since 1999, funding for Medicaid to block grants or a per the number of overdose deaths involving opioids capita allotment approach, and the announcement (including heroin and prescription opioid pain relievers, of President-elect Trump’s selection of Rep. Tom such as hydrocodone, oxycodone, morphine and Price for Secretary of Health and Human Services codeine) nearly quadrupled. From 2000 to 2014, and Seema Verma as the new head of CMS. Price nearly half a million people died from drug overdoses. supports block grants to states and has also Almost two million Americans abused or were proposed requiring “able-bodied” applicants to meet dependent on prescription opioids in 2014. work requirements in order to receive benefits. Although Kansas is not currently experiencing the Verma, who was instrumental in the design and consequences of the opioid epidemic to the same implementation of Medicaid expansion in Indiana, extent as other states, during 2013–2014, more than has previously spoken about the need for states 100,000 Kansans misused prescription pain relievers. to have greater flexibility in the operation of their The number of hospitalizations due to acute poisoning Medicaid programs, which could lead to new from drugs increased threefold from 1999 to 2009, expansion models or other approaches to Medicaid and the number of deaths due to opioid analgesics in non-expansion states such as Kansas. also increased threefold from 1999 to 2013.

The acute drug poisoning rate in Kansas for 2009– State Mental Health Hospitals 2013 was 10.6 per 100,000 people, which falls below the Healthy People 2020 goal of 11.3. However, Following the decertification of Osawatomie State looking at regions in Kansas, the rates vary widely Hospital (OSH)—the state-owned and operated from a low of 5.7 per 100,000 in Southwest Kansas facility providing care for adults diagnosed with to a high of 13.4 per 100,000 in Southeast Kansas. Of psychiatric disorders—by CMS in December 2015, the acute poisonings, the most common specified drug officials with the Kansas Department of Aging and category was opioid analgesics, which constituted 41.1 Disability Services (KDADS) reported in November percent (606) of deaths. that the issues that led to decertification have been addressed. KDADS Acting Secretary Tim Men had a higher likelihood of dying than women from Keck reported during a recent KanCare Oversight acute drug poisoning with 11.6 deaths per 100,000 for Committee meeting that facility upgrades have been completed, staffing has been improved, and OSH is ready for inspection by CMS officials, the final step for recertification. Secretary Keck also Since 1999, the stated that, for now, KDADS has elected to try for number of overdose recertification of only 60 beds at OSH, although he deaths involving hasn’t ruled out seeking recertification of the other 146 beds. opioids has nearly quadrupled in the U.S. KDADS posted a RFP in November to privatize the operation of OSH. The RFP seeks proposals for a five-year contract to operate OSH, with an option to extend it for three additional years. During the 2016 session, the Legislature passed SB 449, which prohibits KDADS from entering into any agreement or action to privatize the operations of OSH without prior authorization by the Legislature.

4 January 2017 2017 Kansas Legislative Preview Kansas males and 9.6 deaths per 100,000 Kansas To date, Kansas has not enacted any naloxone access females. While still below the national average, the or overdose Good Samaritan laws, but should Kansas rate of overdose deaths among people age 12–24 in lawmakers choose to address this growing issue, there are Kansas has quadrupled since 1999. In March 2016, a number of policy options available from other states to health centers in Wichita, Pittsburg and Garden City learn from. were awarded a total of $1.4 million in grants from the U.S. Department of Health and Human Services Medical Marijuana to support their treatment programs for opioid abuse. During both the 2015 and 2016 sessions, Kansas legislators considered and debated several bills related In 2016, more than 30 states enacted legislation to to legalizing marijuana for medical use. In 2016, bills address aspects of the opioid epidemic, including: introduced in both the House and the Senate received hearings and passed out of committee but failed to make • Laws strengthening prescription drug it to the governor’s desk for signature. monitoring programs; and Bills that have provided for more restrictive use, such as • Laws regarding the sale, dispensing, possession the use of hemp oil only (rather than the whole plant) and administration of opioid “rescue drugs” have received the most positive response from legislators. such as naloxone, and immunity for providers It is anticipated that one or more medical marijuana bills of these drugs. will be introduced in 2017.

Some states have also made naloxone available In November 2016, voters in Arkansas, Florida and North without a prescription to further increase access Dakota approved ballot measures for the legalization of and have enacted Good Samaritan laws to allow marijuana for medical use, bringing the total number of people to seek help for themselves or another states that allow medical marijuana to 29, including the experiencing an overdose without prosecution. District of Columbia. With the recent announcement of

Figure 1. Medical Marijuana Laws in the United States, 2016

WA ME MT ND* VT NH OR MN ID SD WI NY MA MI RI WY CT IA PA NJ NV NE OH UT IL IN DE WV MD CA CO VA KS MO KY DC NC TN A OK NM AR* SC

MS AL GA

T LA AK FL*

HI

States that have enacted medical marijuana laws

Note: * In November 2016, voters in Arkansas, Florida and North Dakota approved ballot measures for the legalization of marijuana for medical use. Source: Information compiled by KHI from National Conference of State Legislatures, 2016.

2017 Kansas Legislative Preview January 2017 5 President-elect Trump’s selection of Alabama Sen. enactment of “telehealth parity laws.” These laws require Jeff Sessions—an opponent of legalized marijuana— telehealth service providers to be reimbursed equivalent for U.S. Attorney General, questions have arisen to reimbursements for in-person health services. In the regarding how the federal government will respond absence of these types of parity laws, providers are less to the legalization of marijuana use in the states. likely to implement telehealth options for their patients.

In Kansas, teams of primary care clinicians and other Telemedicine/Telehealth health care professionals, linked with expert specialists at the University of Kansas Medical Center (KUMC), are During the 2016 session, the currently participating in weekly TeleECHO clinics, which established the Interstate Medical Licensure allow the participants to conduct “virtual grand rounds” Compact (IMLC), which will establish a streamlined along with mentoring and patient case presentations. The licensing process for physicians interested in success of these programs, such as the Project ECHO practicing medicine in multiple states. Legislators model at KUMC, may generate interest among legislators saw the IMLC as a way to increase the number to seek ways to expand the use of telehealth modeled of physicians who could potentially provide after the wide variety of alternatives that have been telemedicine services to Kansans, particularly in implemented across the country. rural areas. States like Kansas that struggle with a shortage Scope of Authority/Practice/ of medical professionals have acted to expand Licensing the use of telemedicine and telehealth, including It is anticipated that legislation related to dental therapists and advanced practice registered nurses (APRNs) may be introduced in 2017 to respond to shortages of both The Rural Healthcare Working dental and primary care providers in some parts of the Group, chaired by Lt. Governor state. Jeff Colyer, met through 2016 Legislation concerning APRNs was introduced in 2015 and received a hearing but died in committee in June to explore problems in health 2016. In the past, opponents of such legislation have expressed concerns regarding the quality of care services delivery in rural Kansas. provided by mid-level practitioners if not under direct The group is compiling a set of supervision of dentists or physicians. Twenty-two states have state practice and licensure laws that allow all nurse policy options to address those practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, challenges, and some options and prescribe medications under the exclusive licensure may require legislation. The list authority of the state board of nursing. This is the model recommended by the Institute of Medicine and National is expected to include strategies Council of State Boards of Nursing.

to expand the use of telehealth, In 2016, the Kansas Dental Project introduced SB 413 make it easier for rural hospitals in the Senate Public Health and Welfare Committee, but it received no hearing and died in committee. In and other providers to innovate, 2009, Minnesota became the first state to authorize the licensing of dental therapists (DTs), with a requirement improve access to behavioral that they primarily treat underserved patients. In health services, and address conjunction with the enactment of the law, the Minnesota Legislature directed its Board of Dentistry to consult with workforce shortages across a wide two state agencies to evaluate the impact of the DTs on the delivery of and access to dental services in the state. range of provider types. In a February 2014 report entitled Early Impacts of Dental Therapists in Minnesota, the Minnesota Department of

6 January 2017 2017 Kansas Legislative Preview Health and the Board of Dentistry reported on the paid by the state for millions of state employees and experiences of the DTs practicing in the state, including retirees, prisoners, and low-income people—certain reactions from the patients they served. In addition to state health programs would have been required to Minnesota, two other states, Alaska and Maine, have negotiate the same prices for prescription drugs as enacted mid-level dental practitioner models. the U.S. Department of Veteran Affairs, which are typically deeply discounted. Drug companies spent more than $109 million to oppose the measure Prescription Drug Costs and argued that it would have reduced access to After a sharp spike in spending on prescription drugs medicines and resulted in price increases for others, beginning in 2014 and a number of high-profile price including veterans. The measure also was opposed increases on popular drugs for the treatment of diabetes by veterans’ groups and the California Medical and hepatitis C in 2016, the cost of prescription drugs Association. has become a national conversation. In addition to actions taken by states, prescription Several states have attempted to stall the rise in costs drug costs were addressed by both Donald Trump through cost-saving efforts such as increased price and Hillary Clinton leading up to the November transparency, rebate agreements with pharmaceutical elections. Both Trump and Clinton proposed allowing consumers to import prescription drugs companies for Medicaid programs, and a variety of from foreign nations with safety and quality utilization management practices (e.g., step therapy, standards similar to the U.S. Since the election, cost-sharing, preferred drug lists, limits on quantities President-elect Trump has not announced any plans dispensed). States have also employed pharmacy benefit to address prescription drug costs in the near term. managers (PBMs) to assist in the implementation of a However, the potential repeal of the ACA and any variety of cost-saving strategies. Kansas has implemented subsequent replacement proposals could include strategies for KanCare including step therapy, a preferred steps to curb these rising costs. drug list, and a mandatory 90-day supply provision for maintenance medications.

Though the high cost of pharmaceuticals is widely Budget discussed, concrete policy action is extremely difficult On November 10, 2016, the Consensus Revenue to accomplish. In November, California voters rejected Estimating (CRE) group projected a $346 million Proposition 61, a closely watched proposal in the national shortfall in the state’s revenues for the remainder conversation on the high cost of pharmaceuticals. Under of the current fiscal year, which ends on June 30, this ballot measure—which sought to rein in drug costs 2017, and a decrease of $444 million in projected

2017 Kansas Legislative Preview January 2017 7 revenues for fiscal year 2018, which begins on July service programs, including welfare, foster care, 1, 2017. Following the CRE announcement, Budget KanCare and other medical assistance, will rise by Director Shawn Sullivan stated that no immediate $147 million for the remainder of the current fiscal spending cuts would be made, but that Governor year, but with just $2 million of that increase paid Brownback would be presenting a rescission bill to from state general funds. Beginning in the FY 2018 the Legislature in January. The governor will also be budget, all KanCare expenditures will be included in submitting the new two-year budget to legislators in the budget of KDHE. The Kansas Department for the first weeks of the session. Aging and Disability Services and the Department The Human Services Consensus Caseloads (Figure 2) of Corrections will retain responsibility for their process projected that total spending on social respective programs’ policies and performance.

Figure 2. Human Services Consensus Caseloads, in millions

Human Services Caseload Estimates Fund* FY 2017 FY 2018 FY 2019

SGF $0.3 $0.1 $0.1 Department of Children and Families (DCF): Temporary Assistance to Families AF $15.3 $14.4 $13.5

SGF $99.7 $103.2 $109.0 DCF: Foster Care Contract AF $162.9 $167.1 $174.0

SGF $1.4 — — Department of Corrections (DOC): KanCare AF $3.2 — —

SGF $644.5 $925.0 $1,085.0 Kansas Department of Health and Environment ­(KDHE): KanCare AF $2,080.0 $2,635.0 $2,677.4

SGF $243.6 — — Kansas Department of Aging and Disability Services (KDADS): KanCare AF $666.7 — —

SGF $24.0 $20.5 $20.5 KDADS: Non-KanCare AF $35.7 $26.8 $26.8

SGF $1,013.5 $1,048.8 $1,214.6 TOTALS AF $2,963.8 $2,843.4 $2,891.8

Note: *SGF= State General Fund, AF= All Funds. Some numbers may not sum to totals because of rounding. Source: Kansas Legislative Research Department, November 10, 2016.

ABOUT THE ISSUE BRIEF This brief is based on work done by Carlie J. Houchen, M.P.H., Linda J. Sheppard, J.D., and Kari M. Bruffett. It is available online at khi.org/policy/article/17-02.

KANSAS HEALTH INSTITUTE The Kansas Health Institute delivers credible information and research enabling policy leaders to make informed health policy decisions that enhance their effectiveness as champions for a healthier Kansas. The Kansas Health Institute is a nonprofit, nonpartisan health policy and research organization based in Topeka that was established in 1995 with a multiyear grant from the Kansas Health Foundation. Copyright© Kansas Health Institute 2017. Materials may be reprinted with written permission. Reference publication number KHI/17-02.

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JANUARY 2017